Form 4B The University of the State of New York THE STATE EDUCATION DEPARTMENT Office of the Professions Division of Professional Licensing Services www. op.nysed.gov Speech-Language Pathologist Audiologist Record of Supervised Experience Applicant Instructions Complete Section I.
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How to fill out the Form 4b Application Form online
The Form 4b Application Form is a critical document for applicants seeking licensure in speech-language pathology and audiology. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently online.
Follow the steps to complete the Form 4b Application Form.
- Click the ‘Get Form’ button to access the form and open it in your document editor.
- In Section I, begin by filling in your personal information. Provide your Social Security Number if you have one, leaving it blank if you do not. Enter your birth date (month, day, year) and ensure your name is printed exactly as it appears on your Application for Licensure (Form 1).
- Next, provide your contact details, including your mailing address, daytime phone number, and email address. Make sure to notify the department of any changes to your personal information.
- Specify your supervisor's details in the appropriate fields, including their name, address, telephone number, fax number, and email. You must also indicate the duration of your supervised experience by entering the start and end dates and the total hours worked per week.
- In item 7, read and acknowledge your permission to allow the supervisor to complete Section II of this form. Remember to sign and date this section after your work experience is verified.
- Ensure that your supervisor completes Section II and returns both pages of the form directly to the Office of Professions at the specified address. This form must not be submitted by you, the applicant.
- Review all completed sections for accuracy before saving your changes. After that, you may download, print, or share the form electronically as needed.
Complete your Form 4b Application Form online today for a smooth licensure process!
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